Drill Down: Intensity-Modulated Radiation Therapy (IMRT)

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Original story posted on: June 24, 2013

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All four RAC contractors have issued a complex review for July 18 targeting intensity-modulated radiation therapy (IMRT) provided by physicians and non-physician practitioners. IMRT is provided via a powerful computer-based program that targets radiation to a portion of a field, with the target area determined by the presence or absence of critical structures near a tumor that present in the radiation pathway.

The therapy leverages multiple thin beams of high-yield energy that bombard tumors, leaving normal structures unaffected and using much lower doses of overall radiation than traditional radiation treatment (hence the “modulated”).

The RACs are looking for medical necessity of such therapy and whether diagnoses listed on claims also are listed in the local coverage determination (LCD).

When checking claims against the medical record, look at the coverage indication limitations and/or medical necessity and coding information sections in the LCD that describe the conditions that need to be met in order to satisfy medical necessity and ICD/CPT combinations. The general information section of the LCD lists the documentation requirements, which are quite robust for IMRT: prescription of a treatment plan, need for performing IMRT, an approved IMRT inverse plan (PTV), target verification methodology and documentation, immobilization and positioning documentation, monitor units, fluence distribution in the phantom, respiratory motion, etc.

The review language also references Centers for Medicare & Medicaid Services (CMS) publications 100-02 (Medicare Benefit Policy Manual), 100-04 (Medicare Claims Processing Manual) and 100-09 (Medicare Contractor Beneficiary and Provider Communications Manual).

RAC issues for the week of June 24–28, 2013:

RAC Region A (Performant)     

Ambulatory Surgical Center Claim Types

  • Blepharoplasty - Eyelid Lifts - Blepharoplasty is the plastic repair of the eyelid, and usually refers to an operation in which redundant skin, muscle, and/or fat are excised. Functional blepharoplasty usually involves the excision of skin and orbicularis muscle. This procedure is usually done to correct a deficit in the upper or peripheral field of vision or as noted on forward gaze by skin resting on the upper eyelashes. When blepharoplasty repair is done for cosmetic purposes it does not meet the criteria of the functional visual impairment parameters and is considered not reasonable and medical necessary and therefore will be denied.

Physician/Non-Physician Practitioner Claim Types

  • Intensity-Modulated Radiation Therapy (IMRT) - Region A - Intensity-Modulated Radiation Therapy (IMRT) is a computer-based method of planning for, and delivery of, generally narrow, patient-specific and often temporally modulated beams of radiation to solid tumors within a patient. IMRT is only covered for certain diagnosis and when certain conditions are met.
  • Blepharoplasty - Eyelid Lifts - Blepharoplasty is the plastic repair of the eyelid, and usually refers to an operation in which redundant skin, muscle, and/or fat are excised. Functional blepharoplasty usually involves the excision of skin and orbicularis muscle. This procedure is usually done to correct a deficit in the upper or peripheral field of vision or as noted on forward gaze by skin resting on the upper eyelashes. When blepharoplasty repair is done for cosmetic purposes it does not meet the criteria of the functional visual impairment parameters and is considered not reasonable and medical necessary and therefore will be denied.
  • Annual Wellness Visit (AWV) - J13 - Annual Wellness Visit (AWV) billed more than once in a lifetime, initial.

RAC Region B (CGI)

Inpatient Claim Types

  • Post-Acute Transfer - WPS - The purpose of this automated review is to identify patient discharge status codes improperly reported under Medicare’s Inpatient Prospective Payment System (IPPS) Transfer Policy. This policy applies to all DRGs using the patient discharge status code 02, and specified DRGs using patient discharge status codes 03, 05, 06, 62, 63, and 65. Under the transfer policy, the initial acute care facility shall be paid a per diem rate (up to the full DRG) and the receiving facility shall be paid the full DRG payment. Claims reported as discharge status 01 (to home) rather than as a transfer or claims reported as a transfer reported incorrectly would result in improper payment.
  • Blepharoplasty - Eyelid Lifts (Medical Necessity) - Blepharoplasty is the plastic repair of the eyelid, and usually refers to an operation in which redundant skin, muscle, and/or fat are excised. Functional blepharoplasty usually involves the excision of skin and orbicularis muscle. This procedure is usually done to correct a deficit in the upper or peripheral field of vision or as noted on forward gaze by skin resting on the upper eyelashes. When blepharoplasty repair is done for cosmetic purposes it does not meet criteria of the functional visual impairment parameters and is considered not reasonable and medically necessary and therefore will be denied.
  • Intensity-Modulated Radiation Therapy (Medical Necessity) - Intensity-Modulated Radiation Therapy (IMRT) is a computer-based method of planning for, and delivery of, generally narrow, patient-specific and often temporally modulated beams of radiation to solid tumors within a patient. IMRT is only covered for certain diagnosis and when certain conditions are met.
  • Cancelled Elective Surgeries (Medical Necessity) - When an inpatient hospital admission is based on the expectation that a patient will have elective surgery, but that surgery does not occur, the hospital may bill for the admission only if it remains reasonable and necessary despite the surgery’s cancellation.

 

RAC Region C (Connolly)           

Inpatient Hospital Claim Types

  • Cancelled Elective Surgeries - When an inpatient hospital admission is based on the expectation that a patient will have elective surgery, but that surgery does not occur, the hospital may bill for the admission only if it remains reasonable and necessary despite the surgery's cancellation.

Outpatient Hospital Claim Types

  • Blepharoplasty - Eyelid lifts - Blepharoplasty is the plastic repair of the eyelid, and usually refers to an operation in which redundant skin, muscle, and/or fat are excised. Functional blepharoplasty usually involves the excision of skin and orbicularis muscle. This procedure is usually done to correct a deficit in the upper or peripheral field of vision or as noted on forward gaze by skin resting on the upper eyelashes. When blepharoplasty repair is done for cosmetic purposes it does not meet the criteria of the functional visual impairment parameters and is considered not reasonable and medical necessary and therefore will be denied.
  • Intensity-Modulated Radiation Therapy (IMRT) - Intensity-Modulated Radiation Therapy (IMRT) is a computer-based method of planning for, and delivery of, generally narrow, patient-specific and often temporally modulated beams of radiation to solid tumors within a patient. IMRT is only covered for certain diagnosis and when certain conditions are met.

RAC Region D (HDI)

Critical Access Hospital Claim Types

  • Intensity-Modulated Radiation Therapy (IMRT) - Intensity-Modulated Radiation Therapy (IMRT) is a computer-based method of planning for, and delivery of, generally narrow, patient-specific and often temporally modulated beams of radiation to solid tumors within a patient. IMRT is only covered for certain diagnosis and when certain conditions are met.
  • Blepharoplasty - eyelid lifts (CAH) - Blepharoplasty is the plastic repair of the eyelid, and usually refers to an operation in which redundant skin, muscle, and/or fat are excised. Functional blepharoplasty usually involves the excision of skin and orbicularis muscle. This procedure is usually done to correct a deficit in the upper or peripheral field of vision or as noted on forward gaze by skin resting on the upper eyelashes. When blepharoplasty repair is done for cosmetic purposes it does not meet the criteria of the functional visual impairment parameters and is considered not reasonable and medical necessary and therefore will be denied.

Inpatient Acute Care Hospital Claim Types

  • Cancelled Elective Surgeries - When an inpatient hospital admission is based on the expectation that a patient will have elective surgery, but that surgery does not occur, the hospital may bill for the admission only if it remains reasonable and necessary despite the surgery's cancellation.
  • Intensity-Modulated Radiation Therapy (IMRT) - Intensity-Modulated Radiation Therapy (IMRT) is a computer-based method of planning for, and delivery of, generally narrow, patient-specific and often temporally modulated beams of radiation to solid tumors within a patient. IMRT is only covered for certain diagnosis and when certain conditions are met.
  • Blepharoplasty - eyelid lifts (Acute Inpatient Hospitals) - Blepharoplasty is the plastic repair of the eyelid, and usually refers to an operation in which redundant skin, muscle, and/or fat are excised. Functional blepharoplasty usually involves the excision of skin and orbicularis muscle. This procedure is usually done to correct a deficit in the upper or peripheral field of vision or as noted on forward gaze by skin resting on the upper eyelashes. When blepharoplasty repair is done for cosmetic purposes it does not meet the criteria of the functional visual impairment parameters and is considered not reasonable and medical necessary and therefore will be denied.

Outpatient Hospital Claim Types

  • Intensity-Modulated Radiation Therapy (IMRT) - Intensity-Modulated Radiation Therapy (IMRT) is a computer-based method of planning for, and delivery of, generally narrow, patient-specific and often temporally modulated beams of radiation to solid tumors within a patient. IMRT is only covered for certain diagnosis and when certain conditions are met.
  • Blepharoplasty - eyelid lifts - Blepharoplasty is the plastic repair of the eyelid, and usually refers to an operation in which redundant skin, muscle, and/or fat are excised. Functional blepharoplasty usually involves the excision of skin and orbicularis muscle. This procedure is usually done to correct a deficit in the upper or peripheral field of vision or as noted on forward gaze by skin resting on the upper eyelashes. When blepharoplasty repair is done for cosmetic purposes it does not meet the criteria of the functional visual impairment parameters and is considered not reasonable and medical necessary and therefore will be denied.

About the Author

Dr. Margaret Klasa is the medical director for Context4 Healthcare. She is responsible for the company’s business knowledge discovery unit for medical context as it relates to the daily development of data products and software for medical claims editing and coding, with an emphasis on clinical and regulatory guidelines for Medicare, Medicaid and commercial payors.

Contact the Author

Margaret.Klasa@context4.com

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Margaret Klasa, DC, APN, Bc

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